| NPI | 1568876332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KS 04-38659) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MO 2021039021) |
| Enumeration Date | 2014-06-19 |
| Last Update Date | 2024-04-30 |